Case-based MCQ

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🧠 Case-based MCQ 🔸 #MCQ_51 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 17-year-old girl comes to the physician because of left lower abdominal pain for 1 day. She describes the pain as 6 out of 10 in intensity. Over the past 5 months, she has had similar episodes of pain that occur once a month and last 1 to 2 days. Menses occur at regular 28-day intervals and last 5 to 6 days. Menarche was at the age of 13 years, and her last menstrual period was 2 weeks ago. She has been sexually active with 1 male partner in the past and has used condoms inconsistently. She tested negative for sexually transmitted infections on her last visit 6 months ago. Abdominal and pelvic examination shows no abnormalities. A urine pregnancy test is negative. Which of the following is the most appropriate next step in the management of this patient's symptoms?   A. CT scan of the pelvis B. Diagnostic laparoscopy C. Combined oral contraceptive pill D. Reassurance E. Pelvic ultrasonography

🧠 Case-based MCQ 🔸 #MCQ_50 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is B This patient's symptoms for the last 2 weeks are suggesting acute bacterial rhinosinusitis (ABRS).Acute rhinosinusitis is the symptomatic inflammation of the nasal and sinus mucosa for <4 weeks. The majority of cases are due to viral upper respiratory pathogens (e.g., influenza virus, rhinovirus, adenovirus) and resolve within 10 days. However, 2%-10% of patients develop a secondary bacterial infection, most commonly with Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis. Diagnosis of ABRS is typically made when ≥1 of the following is present: Persistent symptoms/signs of rhinosinusitis for >10 days Severe symptoms, high fever (>39 C [102.2 F]), purulent nasal discharge, and/or facial pain for >3 consecutive days "Double sickening" - initial improvement of viral upper respiratory symptoms for 5-6 days, followed by clinical deterioration (e.g., worsened fever, headache, nasal discharge) Patients with ABRS are usually treated with 5-7 days of oral amoxicillin-clavulanate to reduce symptom duration. Intranasal saline irrigation and analgesics are also often recommended ❌Choice A is not correct: Reassurance and supportive treatment with antipyretics, analgesics, and nasal decongestants are usually sufficient in the treatment of patients with viral rhinosinusitis. However, because this patient has had symptoms for more than 10 days and a mucopurulent discharge suggestive of a bacterial infection, a different treatment is indicated. ❌Choice C is not correct: A CT scan of the paranasal sinuses is not routinely performed in acute sinusitis. It may be used if complications (e.g., osteomyelitis, orbital cellulitis) occur, to rule out differential diagnoses (e.g., neoplasms), or preoperatively in patients with chronic sinusitis (e.g., surgical debridement of necrotic tissue and/or removal of anatomical obstructions). ❌Choice D is not correct: X-ray of the sinuses is usually not recommended in acute sinusitis because it does not help to differentiate between etiologies, and findings from it rarely influence the choice of treatment. ❌Choice E is not correct: Patients with poorly controlled diabetes mellitus (particularly with ketoacidosis) are at risk for rhino-orbital mucormycosis, which is treated with intravenous fungal medications (e.g., Amphotericin B). Manifestations typically progress rapidly and include fever, nasal necrosis, facial swelling, sinusitis, and headache. This patient is on antidiabetic mediations likely has well-controlled diabetes mellitus; he would be at low risk for mucormycosis. ✅Summarized Points: Acute rhinosinusitis is most commonly due to viral pathogens and usually resolves within 10 days. Patients with persistent symptoms >10 days, severe symptoms, or deterioration after several days of improvement often have acute bacterial rhinosinusitis, which is usually treated empirically with 5-7 days of oral amoxicillin-clavulanate. 

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🧠 Case-based MCQ 🔸 #MCQ_50 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 43-year-old man comes to the physician because of nasal congestion and fatigue for 2 weeks. During this period, he has had fevers and severe pain over his cheeks. His nasal discharge was initially clear, but it has turned yellowish over the last couple of days. He has no visual complaints. He has been taking an over-the-counter nasal decongestant and acetaminophen without much relief. He has type 2 diabetes mellitus and hypertension. He underwent an appendectomy 23 years ago. He does not smoke or drink alcohol. His current medications include metformin, sitagliptin, and enalapril. He appears tired. His temperature is 38.5°C (101.3°F), pulse is 96/min, and blood pressure is 138/86 mm Hg. Examination shows purulent discharge in the nose and pharynx and normal-appearing ears. The left maxillary sinus is tender to palpation. Laboratory studies show:   Hemoglobin 146 g/L (125–170)   Leukocyte count 10.8 x 109/L (3.5–10.5)   Platelet count 263 x 109/L (130–380)   ESR 22 mm/hr   Serum Glucose 6 mmol/L (3.3‐5.8)   Which of the following is the most appropriate next step in management? A. Reassurance and follow-up in 1 week B. Oral amoxicillin-clavulanate C. CT scan of the paranasal sinuses D. X-ray of the sinuses E. Intravenous amphotericin B

🧠 Case-based MCQ 🔸 #MCQ_49 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is D Symptoms of spontaneous episodic hypoglycemia that resolve with glucose administration or rest should raise concern for the Whipple triad. If hypoglycemia is not present at the time of evaluation, a 72-hour fasting test is indicated to reproduce hypoglycemic symptoms in order to reach a definitive diagnosis. Glucose and hypoglycemic studies, including measurement of insulin, C-peptide, proinsulin, and β-hydroxybutyrate, should be obtained at the beginning of the test and then repeated every 6 hours until the serum glucose falls below 3.3 mmol/L (60 mg/dL). C-peptide and proinsulin are measures of the endogenous production of insulin and are decreased in hypoglycemia; hypoglycemia with elevated c-peptide and proinsulin levels should raise concern for an insulinoma. ❌Choice A is not correct: A 24-hour urine catecholamine test is used to diagnose pheochromocytoma. This patient's episodic palpitations and diaphoresis may be associated with pheochromocytoma. However, because his symptoms improve with glucose administration, they are consistent with episodic hypoglycemia, which is atypical in patients with pheochromocytoma. ❌Choice B is not correct: A dexamethasone suppression test is a screening test for Cushing syndrome, which could explain this patient's weight gain and fatigue. However, Cushing syndrome more commonly causes hyperglycemia, as opposed to the hypoglycemic episodes seen in this patient. Other clinical features associated with hypercortisolism include central and neck obesity, easy bruising, striae, and proximal muscle weakness, none of which are present. ❌Choice C is not correct: A water deprivation test is used to diagnose diabetes insipidus (DI). Although this patient has a history of hydrochlorothiazide use, which is associated with nephrogenic DI, findings of polyuria, polydipsia, and hypernatremia would be expected. ❌Choice E is not correct: A corticotropin stimulation test is a gold standard for diagnosing primary adrenal insufficiency, which can also manifest with hypoglycemia (due to decreased levels of cortisol), nausea, and fatigue. But adrenal insufficiency would typically lead to hypotension, whereas this patient is normotensive. Moreover, adrenal insufficiency is more commonly associated with weight loss, in contrast to this patient's weight gain. ✅Summarized Points: This patient's episodes of palpitations, nausea, fatigue, and diaphoresis that improve with the consumption of sugar, should raise concern for episodic hypoglycemia.

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🧠 Case-based MCQ 🔸 #MCQ_49 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 60-year-old man comes to the emergency department because of recurrent episodes of fatigue, palpitations, nausea, and diaphoresis over the past 6 months. The episodes have become more frequent in the last 2 weeks and he has missed work several times because of them. His symptoms usually improve after he drinks some juice and rests. He has had a 2-kg (4.5-lb) weight gain in the past 6 months. He has a history of bipolar disorder, hypertension, and asthma. His sister has type 2 diabetes mellitus and his mother has a history of medullary thyroid carcinoma. His medications include lithium, hydrochlorothiazide, aspirin, and a budesonide inhaler. His temperature is 36.3°C (97.3°F), pulse is 92/min and regular, respirations are 20/min, and blood pressure is 118/65 mm Hg. Abdominal examination shows no abnormalities. Serum studies show:   Na+ 145 mEq/L   K+ 3.9 mEq/L   Cl- 103 mEq/L   Ca+2  2.3 mmol/L   Glucose 4.2 mmol/l   Which of the following is the most appropriate next step in diagnosis?   A. 24-hour urine catecholamine test B. Dexamethasone suppression test C. Water deprivation test D. 72-hour fasting test E. Corticotropin stimulation test

🧠 Case-based MCQ 🔸 #MCQ_48 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is D Breast-conserving therapy and sentinel node biopsy are diagnostic and therapeutic procedures used as a first-line intervention in patients with newly diagnosed invasive ductal carcinoma. All patients who undergo lumpectomy require postoperative radiation to the whole breast to minimize the risk of recurrence. Sentinel node biopsy is necessary to stage cancer, which will determine subsequent treatment. Moreover, given the HER2-positive immunohistochemical staining, this patient will benefit from adjuvant systemic chemotherapy in the form of trastuzumab.   ❌Choice A is not correct: Tamoxifen is a selective estrogen receptor modulator that is primarily used in patients with estrogen receptor-positive breast cancer, but this patient's stain is estrogen receptor-negative. ❌Choice B is not correct: A whole-body PET/CT scan is required in all patients with stage IIIA or higher disease to assess for metastases. Additionally, patients who present with signs of metastatic disease, such as abdominal pain, elevated LFTs, or palpable abdominal masses, may benefit from a whole-body PET/CT scan. However, the stage of this patient's cancer has not yet been determined and she does not have any signs of metastatic disease, so a whole-body PET-CT would not be indicated at this time. ❌Choice C is not correct: A bilateral mastectomy with lymph node dissection is commonly performed in patients with bilateral disease, or in patients who have a BRCA gene mutation. Although a BRCA mutation has not explicitly been ruled out in this patient, BRCA mutation carriers generally have a personal and/or family history of breast, ovarian, tubal, or peritoneal cancer, and may also have more advanced disease at presentation (triple-negative or bilateral breast cancer). This patient does not have any of these conditions, which makes a BRCA mutation unlikely. In addition, a HER2 mutation has already been identified as the likely culprit. ❌Choice E is not correct: A bone scan is commonly obtained in patients who present with bone pain or elevated alkaline phosphatase in the setting of newly diagnosed breast cancer, which may be indicative of metastatic disease. This patient does not have either of these findings. ✅Summarized Points: Given the mammography and core-needle biopsy results, this patient most likely has localized breast cancer. She will require further staging and treatment

🧠 Case-based MCQ 🔸 #MCQ_48 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The patient undergoes a mammogram, which shows a 6.5mm sized mass with an irregular border and spiculated margins. A subsequent core needle biopsy of the mass shows infiltrating ductal carcinoma with HER2-positive, estrogen-negative, and progesterone-negative immunohistochemistry staining. Blood counts and liver function tests are normal. Laboratory studies show:   Hemoglobin 125 g/L  Serum   Na+ 140 mEq/L   Cl- 103 mEq/L   K+ 4.2 mEq/L   HCO3- 26 mEq/L   Ca+2 2.29 mmol/L   Urea Nitrogen 4.2 mmol/L   Glucose 6.1 mmol/L   Alkaline Phosphatase 25 U/L   Alanine aminotransferase (ALT) 15 U/L   Aspartate aminotransferase (AST) 13 U/L   Which of the following is the most appropriate next step in management?   A. Tamoxifen therapy B. Whole-body PET/CT C. Bilateral mastectomy with lymph node dissection D. Breast-conserving therapy and sentinel lymph node biopsy E. Bone scan